经皮椎体后凸成形术治疗老年骨质疏松性椎体压缩性骨折患者40例疗效观察

目的探讨经皮椎体后凸成形术治疗老年骨质疏松性椎体压缩性骨折患者疗效观察及近、中期预后效果。方法选取我院79例老年骨质疏松性椎体压缩性骨折患者,依据手术术式不同分组,对照组39例采用经皮椎体成形术治疗,观察组40例给予经皮椎体后凸成形术治疗,观察比较两组术前、术后3个月、术后12个月Oswestry功能障碍指数(ODI)评分、疼痛(VAS)评分及手术前后伤椎Cobb角、椎体压缩率变化情况,并统计两组并发症发生率。结果术后3个月及12个月两组ODI、VAS评分均低于术前,观察组术后3个月伤椎Cobb角及椎体压缩率均小于对照组,差异有统计学意义(P0.05);观察组并发症发生率为2.50%(1/40),低于对照组20.51%(8/39),差异有统计学意义(P0.05)。结论给予老年骨质疏松性椎体压缩性骨折患者经皮椎体后凸成形术治疗,效果较佳,可矫正畸形,促进椎体高度恢复,降低并发症发生率。     

经皮椎体后凸成形术治疗创伤性胸腰椎椎体压缩性骨折的近期疗效

目的探讨经皮椎体后凸成形术(PKP)治疗创伤性胸腰椎椎体压缩性骨折的近期疗效及安全性。方法将80例胸腰椎椎体压缩性骨折手术患者随机分为观察组和对照组,各40例。对照组采用传统的椎弓根钉椎体成形术,观察组行经皮椎体后凸成形术,比较2组治疗效果。结果 2组术后VAS评分、后凸Cobb角和椎体高度均较术前明显改善,差异有统计学意义(P0.05)。观察组后凸Cobb角、椎体高度改善优于对照组,术后并发症发生率低于对照组,差异均有统计学意义(P0.05)。结论 PKP治疗创伤性胸腰椎椎体压缩性骨折并发症少,功能恢复好,近期疗效肯定。     

单侧和双侧经皮椎体成形术治疗胸腰椎骨质疏松性压缩性骨折的疗效比较

目的比较经单侧与双侧穿刺行经皮椎体成形术治疗胸腰椎骨质疏松性压缩性骨折的疗效。方法选取2013-2016年收治的160例胸腰椎骨质疏松性压缩性骨折作为研究对象,随机分为单侧组和双侧组,各80例。分别行单侧PVP和双侧PVP治疗,对比两组患者治疗情况。结果单侧组手术时间、X线暴露时间明显短于双侧组,骨水泥渗漏发生率明显小于双侧组,差异显著(P0.05);两组术前及术后椎体后凸Cobb角、椎体高度压缩率、ODI及VAS组间无明显差异(P0.05);两组患者术后椎体后凸Cobb角、椎体高度压缩率、ODI及VAS较术前均有明显改善(P0.01);术后3个月及之前,两组间生活质量评分无明显差异(P0.05);术后6个月及之后,双侧组病患生活质量评分明显高于单侧组(P0.05)。结论经单侧与双侧穿刺行经皮椎体成形术治疗胸腰椎骨质疏松性压缩性骨折均具有显著疗效,但单侧PVP具有骨水泥渗漏发生率低、X线暴露时间短、手术时间短等优点。     

PKP联合手法复位治疗老年胸腰椎压缩性骨折的临床疗效

目的探讨经皮穿刺球囊扩张椎体成形术(PKP)联合手法复位治疗老年胸腰椎压缩性骨折的疗效及对患者椎体复位情况的影响。方法选择本院于2019年6月至2020年12月期间收治的78例老年胸腰椎压缩性骨折患者为研究对象,按治疗方案划分为研究组(n=39)和对照组(n=39),两组患者均行PKP治疗,研究组加以手法复位治疗,比较分析两组患者手术效果、手术前后疼痛程度及椎体复位情况。结果研究组Cobb角、X线投照次数、椎体压缩比均较对照组明显更低,椎体高度较对照组明显更高(P0.05)。术前与术后7d两组患者VAS评分、ODI评分对比差异均无统计学意义(P0.05),术后1个月、3个月研究组VAS评分及ODI评分均较对照组明显更低(P0.05)。结论 PKP联合手法复位治疗有助于减少老年胸腰椎压缩性骨折手术创伤,降低疼痛程度,促进术后椎体复位,值得临床应用。     

两种椎体成形术对老年骨质疏松症椎体压缩性骨折患者治疗效果的分析

目的探讨经皮椎体成形术和经皮椎体后凸成形术治疗老年骨质疏松症椎体压缩性骨折的效果。方法随机将92例老年骨质疏松症椎体压缩性骨折患者分成2组,各46例。对照组行经皮椎体成形术,观察组行经皮椎体后凸成形术。结果观察组下床活动时间、住院时间、患椎增加高度和骨水泥注射量均明显优于对照组,差异有统计学意义(P 0. 05)。2组治疗前的Cobb角、ODI指数、椎体压缩率、VAS评分差异无统计学意义(P 0. 05)。治疗后,观察组以上指标均明显优于对照组,差异有统计学意义(P 0. 05)。观察组术后并发症发生率低于对照组,差异有统计学意义(P 0. 05)。结论与经皮椎体成形术比较,经皮椎体后凸成形术治疗老年骨质疏松症椎体压缩性骨折,住院时间短、术后并发症少、椎体矫正效果好、缓解疼痛迅速,但需严格把握手术适应证。     

经皮穿刺椎体成形术结合体位复位在老年胸腰椎压缩性骨折中的应用效果

目的研究经皮穿刺椎体成形术(percutaneous vertebroplasty,PVP)结合体位复位在老年胸腰椎压缩性骨折中的应用效果。方法选取从2014年2月到2017年2月共150例在本院进行治疗的老年胸腰椎压缩性骨折的患者作为研究对象,以随机数字表法分为两组,每组75例。观察组应用PVP结合体位复位治疗,对照组的治疗方式为经皮球囊扩张椎体后凸成形术(percutaneous kyphoplasty,PKP)。结果观察组总有效率94.67%;对照组总有效率96%。观察组总有效率与对照组比较,差异无统计学意义(P>0.05)。两组治疗后,观察组Cobb角与对照组比较无显著差异,椎体前缘和后缘压缩率明显高于对照组,差异有统计学意义(P<0.05)。经治疗两组患者Oswestry功能障碍指数和VAS评分显著下降;观察组治疗后Oswestry功能障碍指数及VAS评分与对照组比较差异无统计学意义(P>0.05)。结论 PVP结合体位复位和PKP术治疗老年胸腰椎压缩性骨折均具有良好效果,能显著改善患者的临床症状及生活质量,PKP对椎体高度的恢复作用更为显著,而PVP适应证更广,操作更简便,价格较低。     

手法复位联合经皮椎体成形术治疗老年骨质疏松性椎体压缩性骨折的效果

目的分析手法复位联合经皮椎体成形术(PVP)治疗老年骨质疏松性椎体压缩性骨折的临床效果。方法将64例老年骨质疏松性椎体压缩性骨折患者随机分为2组,每组32例。对照组行PVP,观察组应用手法复位联合PVP。比较2组的疗效。结果观察组治疗后3个月的VAS评分、ODI指数、椎体前缘压缩率(CR%)、Cobb's角等指标,均优于对照组,差异有统计学意义(P0.05)。结论手法复位联合PVP治疗老年骨质疏松性椎体压缩性骨折,可增强患者的椎体强度、稳定性和疼痛症状的改善,有利于提高患者的生活质量。     

新型脊柱复位器联合PVP治疗胸腰椎压缩骨折的应用分析

目的探讨新型(基于放射学参数设计)脊柱复位器在经皮椎体成形术(percutaneous vertebroplasty,PVP)治疗胸腰椎压缩骨折的应用价值。方法回顾性分析自2016年3月至2018年3月住院治疗的79例胸腰椎压缩骨折患者,按住院先后顺序随机分为脊柱复位器+PVP治疗组43例和单纯PVP治疗对照组36例,观察两组患者治疗前及治疗后椎体前缘压缩率、视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(oswestry disability index,ODI)评分情况。结果两组患者治疗前的椎体前缘压缩率、VAS及ODI评分比较差异无统计学意义(P0.05)。治疗后60 d椎体前缘压缩率、VAS及ODI评分较治疗前均显著降低,两组评分比较差异有统计学意义(P0.05)。结论基于放射学参数设计脊柱复位器联合PVP治疗胸腰椎压缩骨折能显著恢复椎体前缘压缩率并改善患者术后脊柱功能状态,较单纯PVP治疗疗效更佳,值得临床进一步应用推广。     

经皮椎弓根固定联合椎体成形术治疗胸腰椎骨质疏松性骨折

[目的]探讨经皮椎弓根内固定联合椎体后凸成形术在治疗胸腰椎骨质疏松性压缩骨折中的应用。[方法]2014年12月~2016年5月在本院就诊的骨质疏松性胸腰椎骨折患者106例,随机分为经皮椎弓根内固定联合椎体后凸成形术治疗组(联合组)和单纯经皮椎体后凸成形术治疗组(对照组),联合组54例,对照组52例,所有患者均为单椎体,于术前、术后和末次随访采用视觉疼痛模拟量表(VAS)、Oswestry功能障碍指数(ODI)、Cobb角及椎体前缘高度压缩率评定临床效果。[结果]所有患者顺利完成手术,均获随访,时间15~19个月。术前两组患者VAS评分、ODI指数、Cobb角度变化及椎体前缘高度压缩率的差异均无统计学意义(P>0.05),但末次随访时,联合组上述指标数值均小于对照组,组间比较差异有统计学意义(P<0.05)。[结论]经皮椎弓根内固定联合椎体后凸成形术治疗胸腰椎骨质疏松性压缩骨折创伤小,可以更好地恢复脊柱稳定性,有效维持伤椎的形态完整及强度、高度,从而减轻疼痛,提高患者生存质量。     

手术联合金天格胶囊治疗老年骨质疏松性胸腰椎压缩性骨折临床体会

目的观察和分析经皮椎体成形术联合金天格胶囊治疗老年骨质疏松性胸腰椎压缩性骨折的效果。方法随机将120例老年骨质疏松性胸腰椎压缩性骨折患者分成对照组和观察组,每组60例。2组均给予经皮椎体成形术治疗,在此基础上对照组联合常规钙剂治疗,观察组联合金天格胶囊治疗。分析比较2组治疗效果、视觉模拟评分法(visual analogue scale,VAS)及骨密度变化等指标。结果 2组总有效率比较,差异无统计学意义(P>0.05)。但治疗2个月后,观察组VAS评分低于对照组、骨密度测定值优于对照组,2组比较,差异有统计学意义(P<0.05)。结论经皮椎体成形术联合金天格胶囊治疗老年骨质疏松性胸腰椎压缩性骨折,能明显提高患者骨密度、缓解疼痛,效果肯定。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.